Download Pelvic Organ Prolapse

Pelvic Floor Dysfunction
Chen Xiaojun
Ob&Gyn Hospital Fudan Uniiversity
Obstetrics & Gynecology Hospital
Fudan University
What you need to know
• Anatomy of pelvic floor and etiology of pelvic
floor dysfunction
• Definition and major types of pelvic organ
prolapse
• Principle of treatment
• Types of urinary incontinence
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• Pelvic Organ Prolapse
• Lower Urinary Tract disorder
• Anorectal Disorder
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Pelvic floor dysfunction
• Not life threatening
• But life quality worsening
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Pelvic Floor
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Pelvic floor
Pelvic outlet
Anterior
pubic symphysis
Posterior
apex of coccys
Bilateral
descending ramus of pubis
ascending ramus of ischium
ischial tuberosity
ischial spine
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Pelvic floor
Pelvic Supports
Muscle
Fasciae and ligament
• 神经支配；
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Pelvic Floor
Pelvic diaphragm
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Funnel-shaped
fibromuscular partition
Forms the primary
supporting structure for the
pelvic contents
Composition
– Levator ani
– Coccygeus muscles
– their superior and inferior fasciae
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Forms the ceiling of the
ischiorectal fossa
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女性会阴.浅表分割
阴蒂clitoris------------------------------尿道外口--------------------------External urethral orific
阴道口--------------------------Vaginal orific
外层
---------------------坐骨海绵体肌 ischocavernosus
--------------------球海绵体肌bulbocavernosus
---------------会阴浅横肌
superficial transverse perineal muscle
-----------------------肛门外括约肌
External anal sphincter
由会阴浅筋膜与肌肉组成，
包括会阴浅横肌、球海绵体肌、坐骨海绵体肌和肛门外括约肌。
女性会阴和尿生殖膈
---------------------尿道括约肌
urethral sphincter
尿生殖膈下筋膜---------------Inferior fascia of urogenital diaphragm
----------------尿生殖膈上筋膜
Superior fascia of urogenital diaphragm
会阴深横肌
Deep transverse perineal muscle
中层
为尿生殖膈，由上、下两层坚韧筋膜及一层薄肌肉组成。
覆盖在耻骨弓及两坐骨结节间所形成的骨盆出口前部的三角平面上。
包括会阴深横肌及尿道括约肌。
Levator ani
Strongest support of pelvic
floor
女性骨盆横膈:俯视图
----------------------耻骨阴道肌
Pubovaginal muscle
Tendinous fascia pelvis
“the white line”
---------------------耻骨直肠肌
Puborectal muscle
-----------------------耻骨尾骨肌
Pubococcygeal muscle
髂骨尾骨肌
Iliaccoccygeal muscle
坐骨尾骨肌
ischiococcygeus
内层 称为盆膈，为盆底最里层，最坚韧的组织。
由肛提肌、盆筋膜组成，有尿道、阴道、直肠贯穿其中。
Levator ani
• Support pelvic organs
• Inforce sphincters
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The hammock hypothesis
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3 levels of support
• Level 1 - Apical Support
Superior suspension of the vagina to the cardinaluterosacral complex
• Level 2—Lateral Support
Lateral attachment of the upper 2/3 of the vagina
• Level 3 – distal support
Fusion of the vagina into the urogenital diaphragm and
perineal body
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Pelvic floor 3 compartments
• Anterior compartment (bladder and urethra)
• Middle compartment (vagina and uterus)
• Posterior compartment (anorectus)
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Integral theory
Prolapse and most pelvic floor symptoms such as urinary stress,
urge, abnormal bowel and bladder emptying, and some forms of
pelvic pain, mainly arise, for different reasons, from laxity in the
vagina or its supporting ligaments, a result of altered connective
tissue.
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Pelvic floor dysfunction
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Level 1 – prolapse of the uterus or anterior vaginal vault
Level2/3 – prolapse of anterior or posterior vaginal wall
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Anterior compartment –
 lower urethral tract dysfunction
Middle compartment –
 Enterocele
 Cystocele
 Uterine prolapse
Posterior compartment
 Rectocele
 Anorectal dysfunction
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•
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PELVIC ORGAN PROLAPSE
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Pelvic Organ Prolapse (POP)
• Bulge or protrusion of pelvic organs and their
associated vaginal segments into or through
the vagina
• Incidence increases with aging
– anterior pelvic organ prolapse 34.3%
– posterior wall prolapse 18.6%
– uterine prolapse in 14.3%
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Pelvic Organ Prolapse (POP)
• Vaginal delivery as a significant risk factor
• History of hysterectomy; obesity ; history of previous
prolapse operations; race
• Optional surgical treatment remains elusive
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Pathophysiology
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Attenuation of the supportive
structures
– endopelvic connective
tissue
– levator ani muscular support
 by actual tears or “breaks”
 by neuromuscular
dysfunction
Continuous abdominal pressure
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Definitions
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Rectocele
Enterocele
Cystocele
Uterine prolapse
– Procidentia
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Definitions
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Symptoms
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Pelvic organ prolapse
Symptoms of voiding dysfunction
– Urinary incontinence
– Urinary urgency and frequency
– Obstructive voiding symptoms
– Urinary retention and upper renal compromise
Defecatory problems (e.g., constipation, diarrhea, tenesmus, fecal
incontinence)
Pelvic pain
Back and flank pain
Overall pelvic discomfort
Dyspareunia
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Symptoms
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Physical examination
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Divide the pelvis into compartments
Apical compartment ---- Graves speculum or Baden retractor
The anterior and posterior compartments ---- univalve or Sims' spe
Rectovaginal examination ---- distinguish a posterior vaginal wall d
a dissecting apical enterocele
Anterior lateral detachment defect----Baden retractor
Valsalva is encouraged
Standing straining examination
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Pelvic Organ Prolapse Quantitation System
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Pelvic Organ Prolapse Quantitation System
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Pelvic Organ Prolapse Quantitation System
>1
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• Pelvic Muscle Function Assessment
• Bladder Evaluation
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Treatment
• Nonsurgical Therapy
– Mild to moderate prolapse
– Desire future childbearing
– Not suitable or desiring surgery
Always conservative therapy first!!!
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Conservative Management
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Pelvic floor muscle training (PFMT)
Lifestyle intervention
– weight loss
– reduction of activities that increase intra–abdominal
pressure
Mechanical Devices
− Pessary
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Surgical Management
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OPTIONAL!!!
Relieve symptoms
Restore vaginal anatomy
Vaginal, abdominal, and laparoscopic routes
Involve a combination of repairs directed to the anterior vagina,
vaginal apex, posterior vagina, and perineum
• NONE IS PERFECT!
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Surgical Management
Procedures
• Restorative: use the patient's endogenous support structures
• Compensatory: replace deficient support with permanent graft
material
• Obliterative: close or partially close the vagina.
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Obstetrics & Gynecology Hospital
Fudan University
Key points
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With the aging of the population, pelvic organ prolapse is an increasingly common
condition seen in women.
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Causes of pelvic organ prolapse are multifactorial and result in weakening of the
pelvic support connective tissue and muscles as well as nerve damage.
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Patients may be asymptomatic or have significant symptoms such as those relating to
the lower urinary tract, pelvic pain, defecatory problems, fecal incontinence, back pain,
and dyspareunia.
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Physical examination includes thoughtful attention to all parts of the vagina, including
the anterior, apical, and posterior compartments, levator muscle, and anal sphincter
complex.
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Key points
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Nonsurgical treatment options include pelvic floor muscle training and the
use of intravaginal devices.
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Surgical treatment involves an individualized, multicompartmental approach
consistent with the patient‘s previous treatment attempts, activity level, and
health status.
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LOWER URINARY TRACT DISORDERS
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Normal Urethral Closure
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Urinary incontinence
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Stress Urinary Incontinence
• Most common type of urinary continence in women
• Leaking when sneezing, coughing, or exercise
• Urethral sphincter defect and/or urethral hypermobility
Urge Urinary Incontinence and Overactive Bladder
• Most common form of incontinence in older women
• Involuntary leakage of urine accompanied by or
immediately preceded by urgency
• May or may not be caused by detrusor overactivity
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Urinary incontinence
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Mixed Incontinence
• Have symptoms of both stress and urge urinary incontinence
• In older women mixed and urge incontinence is predominate
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Stress urinary incontinence
• Incidence
US
15-35 %
Korea
50%
China 18.9 %
• Age
Postmenopausal women 17%.
Affects 50 million people in the world.
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Pathophysiology
• Stress urinary incontinence
 Incontinence caused by anatomic hypermobility of the urethra
 Incontinence caused by intrinsic sphincteric weakness or deficiency
• Urgent urinary incontinence
 Bladder
 Innervation
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Risk factors
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Age
Obesity
Functional impairment
Cognitive impairment
Pregnancy and delivery
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Evaluation
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Hisotory (medications, operations...)
Quality of life measures
Physical examination (Q–tip test)
Primary care level tests
 Voiding Diary
 Urinalysis
 Postvoid Residual Volume
 Cough Stress Test
 Pad Tests
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Evaluation
• Advanced testing
 Urodynamics
 Uroflowmetry
 Filling cystometry
 Voiding cystometrography
 Imaging tests
 Neurophysiological tests
 …….
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Nonsurgical treatment
• Lifestyle Changes
 Weight loss
 Postural change
 Decrease caffeine intake
• Physical Therapy -- SUI
 Pelvic floor muscle training
• Behavioral Therapy and Bladder Training – UI & OAB
• Vaginal and urethral devices --SUI
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Vaginal and Urethral Devices
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Medications
• Stress incontinence
– α– adrenergic activity
• Urge Incontinence and Overactive Bladder
– anticholinergic agents
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Surgical Treatment for Stress incontinence
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TVT/SPARC
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Key Points
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Anorectal Dysfunction
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Clasification
• Defecatory dysfunction --- constipation
Infrequent stools, typically fewer than three bowel movements
per week.
• Fecal Incontinence
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Key points
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Defecatory dysfunction and fecal incontinence are common conditions that
have tremendous psychosocial and economic implications.
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The differential diagnosis for anorectal dysfunction is broad and can be
classified into systemic factors, anatomic and structural abnormalities, and
functional disorders.
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A thorough history and physical examination is critical for the evaluation of
fecal incontinence and defecatory dysfunction, as well as appropriate
ancillary testing.
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Key points
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Treatment of anorectal dysfunction should focus on treatment of
the underlying condition with nonsurgical management attempted
before surgery.
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Overlapping sphincteroplasty is the procedure of choice for fecal
incontinence caused by a disrupted anal sphincter.
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Questions
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Which structure is the strongest support of the pelvic floor?
The types of pelvic organ prolapse and their definition.
The principle of treatment of pelvic organ prolapse.
Types of urinary incontinence and their definition.
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Thank you !
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